Interim guidance for poliomyelitis (polio) surveillance network in the context of coronavirus disease (COVID-19) – Update 25 March 2021

Introduction

The coronavirus disease (COVID-19) pandemic is an unprecedented global event that has required adjustments to routine surveillance activities for detection of polioviruses to ensure the personal safety of surveillance related personnel in the field and/or laboratory – surveillance officers, laboratory technicians/scientists, healthcare workers, and community members. This document aims to update global guidance on AFP/polio surveillance in the context of the COVID-19 pandemic and is a technical replacement for the Interim guidance for poliomyelitis (polio) surveillance network in the context of coronavirus disease (COVID-19)1 published in May 2020. The previous guidance included standard operating procedures that specified how to modify the following surveillance-specific activities as the risk mitigation measures and effects of the COVID-19 pandemic continued to evolve:

• Active acute flaccid paralysis (AFP) surveillance • Investigation of poliovirus type 2 isolation in the environment • Community based surveillance for polio • Acute flaccid paralysis (AFP) case investigation • Detailed polio case investigation • Guidance on the prioritization for storage, shipment, and testing of polio surveillance samples Since the COVID-19 pandemic began over a year ago, mitigation measures to prevent the spread of SARS-CoV-2 have been adopted by countries. Programs including the Global Polio Eradication Initiative (GPEI) have implemented these measures, which have now become the “new normal” for operations. The updated guidance aligns with this new way of working. This guidance recommends resumption of polio surveillance activities where feasible, per standard GPEI and Global Polio Laboratory Network (GPLN) guidance; however, local, national, and regional variations in SARS-CoV-2 transmission and response should be considered. At the discretion of regional and country leadership, further adaptation of the guidance or specific modification for regional or country context may be needed.

The specific objective of this guidance document is to:

• Describe measures that can be undertaken to reduce or prevent the spread of SARS-CoV-2 while conducting surveillance activities for detection of polioviruses National polio surveillance programs can conduct surveillance activities as long as these are in accordance with local and national mandates. At all times, polio surveillance personnel should practice safety precautions such as use of personal protective equipment (PPE) and physical distancing when conducting activities.

1 Interim guidance for the poliomyelitis (polio) surveillance network in the context of coronavirus disease (COVID-19). Geneva: World Health Organization, 2020. (https://www.who.int/publications/i/item/WHO-POLIO-20.04) 1 | P a g e

As countries implement this guidance and adapt to the local context, the programme must remember not to compromise on the safety and security of surveillance officers and other polio staff and adhere to the principles of “do no harm” and “duty of care” by limiting direct contact with patients/individuals, maintaining appropriate physical distancing and ensuring that all health care workers are fully trained and have appropriate PPE2,3 .

Recommendations for in-person activities

Polio surveillance personnel who conduct field polio surveillance activities should be provided with, as a minimum, hand sanitizers or handwashing supplies if access to clean water is available, face masks, and disinfectant solution to clean surfaces. Protective measures in place for polio surveillance prior to the COVID-19 pandemic such as gloves for collecting stool specimens or other PPE for environmental surveillance sample collection will similarly protect from SARS-CoV-2 transmission. In situations where programme personnel are at increased risk of contracting COVID-19 (e.g., during case specimen collection and handling, in-person case investigations and active surveillance visits), additional measures including the provision of gloves should be considered. Polio surveillance personnel should receive the COVID-19 vaccine in accordance with national/Ministry of Health instructions and prioritization.

General

• Maintain at least 1-meter (approximately 3 feet) distance between individuals and, if not possible, ensure proper use of non-medical mask • Wear non-medical mask in indoor (e.g. offices, shared workplaces, clinics) regardless of whether physical distancing of at least 1 metre can be maintained or outdoor settings where physical distancing of at least 1 metre cannot be maintained4 • Perform hand hygiene after conducting in-person activities with soap and water or hand sanitizer containing 60-80% alcohol Visiting health facilities

• Conduct activities (i.e., medical records review) in a well-ventilated space, outdoors and/or by maintaining recommended physical distancing as often as possible • All personnel should practise good hand hygiene5 before and after each direct person encounter

2 Overview of public health and social measures in the context of COVID-19: interim guidance. Geneva: World Health Organization; 2020 (https://www.who.int/publications-detail/overview-of-public-health-and-social-measures-in-the-context-of-covid-19). 3 Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance. Geneva: World Health Organization; 2020. (https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is- suspected-20200125). 4 Mask use in the context of COVID-19. Geneva: World Health Organization; 2020. Advice on the use of masks in the community, during home care and in healthcare settings in the context of the novel coronavirus (COVID-19) outbreak (who.int) 5 WHO save lives, clean your hands in the context of COVID-19. Geneva: World Health Organization; 2020. https://www.who.int/publications/m/item/who-saves-lives-clean-your-hands-in-the-context-of-covid-19 2 | P a g e

• Disinfect any surfaces with a chlorine or alcohol-based solution before and after use6 Visiting communities

• Conduct activities (i.e., interviews, visual assessments) in a well-ventilated space, outdoors and/or by maintaining recommended physical distancing as often as possible. • Avoid crowded areas by – o Limiting the number of people involved in an activity to those who are essential o Conducting virtual/telephone activities where possible • All personnel should practise good hand hygiene before and after each direct person encounter Trainings and meetings

• Recommend continuing to conduct maximally virtual meetings and trainings until there are compelling situations. In-person meetings and training sessions should be conducted in well- ventilated (e.g., open windows) and frequently disinfected areas; and reports of such activities MUST mention reasons (for in person training ) • Limit number of people gathered according to national or local guidelines7 • Consult web-based GPEI training modules on basics of surveillance that are suited to the ‘new norms’. These are most likely to be available by Xxxx, 2021. •

Considerations for implementation Polio surveillance activities implemented in the context COVID-19 require special considerations to ensure the safety of polio staff and community members. The following principles should be reviewed and incorporated into practice by regional and country leadership overseeing activities (general) and staff executing activities (individual).

General8

• Tailor strategies to enable safest, most effective implementation of surveillance activities. This may translate to web or telephone-based implementation in areas with community transmission. • Involve community leaders in surveillance activities conducted in the community; work with the community to minimize risk of SARS-CoV-2 transmission during surveillance activities • Ensure adequate access to PPE supplies, e.g. masks, hand sanitizer or hand washing units with soap and water

Individual

6 Cleaning and disinfection of environmental surfaces in the context of COVID-19. Geneva: World Health Organization; 2020. https://www.who.int/publications/i/item/cleaning-and-disinfection-of-environmental-surfaces-inthe-context-of-covid-19 7 Interim Guidelines for Frontline Workers on Safe Implementation of House-To-House Vaccination Campaigns (25 June 2020). Geneva: World Health Organization; 2020. INTERIM guidelines FOR FRONTLINE WORKERS on safe implementation of house-to-house vaccination campaigns (25 JUNE 2020) (polioeradication.org) 8 Framework for decision-making: implementation of mass vaccination campaigns in the context of COVID-19. Geneva: World Health Organization; 2020. Framework for decision-making: implementation of mass vaccination campaigns in the context of COVID-19 (who.int)

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• In-person surveillance activities should be undertaken if steps can be made to mitigate SAR-CoV-2 transmission • An individual’s own comfort and risk level including vulnerabilities like age and other health conditions should be assessed before undertaking any surveillance activities • Adhere rigorously to PPE measures and risk mitigation measures (e.g., handwashing, physical distancing) to protect surveillance officers and other polio staff against SARS-CoV-2 and other pathogens transmitted via person-to-person9 • Avoid meeting with any individuals with symptoms of COVID-19 and encourage people with symptoms to seek care

Moving forward in implementing polio surveillance activities at the country level

Depending on the COVID-19 situation, the scale of the polio surveillance activities that can be conducted may vary, which has been observed since the pandemic began. Several challenges to the program have emerged including diversion of polio resources to support the COVID-19 response, limitations in the ability to perform routine activities due to lockdowns and other movement restrictions, and bottlenecks with specimen transport within and between countries. In some cases this has resulted in the decline in AFP case reporting and sewage specimen collection, delays in transport, and limited surveillance activities.10 If support to the COVID-19 response is provided by polio personnel, a back-up should be assigned to critical roles (e.g. surveillance focal persons) to maintain continuity of polio surveillance functions whenever possible. Innovative solutions and adaptations to challenges in national and local programs have been and remain critical to ensuring polio surveillance is optimal.

9 Rational use of personal protective equipment for coronavirus disease (COVID-19) and considerations during severe shortages. Geneva: World Health Organization; 2020. Rational use of personal protective equipment for coronavirus disease (COVID-19) and considerations during severe shortages (who.int) 10 Zomahoun DJ, Burman AL, Snider CJ, et al. Impact of COVID-19 Pandemic on Global Poliovirus Surveillance. MMWR Morb Mortal Wkly Rep 2021;69:1648–1652. DOI: http://dx.doi.org/10.15585/mmwr.mm695152a4

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